The Alopecia Areata Severity and Morbidity Index (ASAMI) Study: Results From a Global Expert Consensus Exercise on Determinants of Alopecia Areata Severity.

Importance: Current measures of alopecia areata (AA) severity, such as the Severity of Alopecia Tool score, do not adequately capture overall disease impact. Objective: To explore factors associated with AA severity beyond scalp hair loss, and to support the development of the Alopecia Areata Severity and Morbidity Index (ASAMI). Evidence Review: A total of 74 hair and scalp disorder specialists from multiple continents were invited to participate in an eDelphi project consisting of 3 survey rounds. The first 2 sessions took place via a text-based web application following the Delphi study design. The final round took place virtually among participants via video conferencing software on April 30, 2022. Findings: Of all invited experts, 64 completed the first survey round (global representation: Africa [4.7%], Asia [9.4%], Australia [14.1%], Europe [43.8%], North America [23.4%], and South America [4.7%]; health care setting: public [20.3%], private [28.1%], and both [51.6%]). A total of 58 specialists completed the second round, and 42 participated in the final video conference meeting. Overall, consensus was achieved in 96 of 107 questions. Several factors, independent of the Severity of Alopecia Tool score, were identified as potentially worsening AA severity outcomes. These factors included a disease duration of 12 months or more, 3 or more relapses, inadequate response to topical or systemic treatments, rapid disease progression, difficulty in cosmetically concealing hair loss, facial hair involvement (eyebrows, eyelashes, and/or beard), nail involvement, impaired quality of life, and a history of anxiety, depression, or suicidal ideation due to or exacerbated by AA. Consensus was reached that the Alopecia Areata Investigator Global Assessment scale adequately classified the severity of scalp hair loss. Conclusions and Relevance: This eDelphi survey study, with consensus among global experts, identified various determinants of AA severity, encompassing not only scalp hair loss but also other outcomes. These findings are expected to facilitate the development of a multicomponent severity tool that endeavors to competently measure disease impact. The findings are also anticipated to aid in identifying candidates for current and emerging systemic treatments. Future research must incorporate the perspectives of patients and the public to assign weight to the domains recognized in this project as associated with AA severity.

The dermatoscope in the hair clinic: Trichoscopy of scarring and nonscarring alopecia.

Trichoscopy is currently regarded as an essential part of the hair loss consultation. It allows visualization of morphologic structures that are not obvious to the naked eye, including peri- and interfollicular skin surface abnormalities and changes to hair shaft thickness and shape. In this paper, we aim to discuss current knowledge on trichoscopy of the most common forms of scarring and nonscarring alopecias.

Defining Severity in Alopecia Areata: Current Perspectives and a Multidimensional Framework.

Alopecia areata (AA) is an autoimmune disease characterized by nonscarring hair loss. As a clinically heterogeneous disease, various classification systems have evolved for defining its severity. In this high-level review of the literature, we discuss the traditional classification systems for AA severity and their strengths and weaknesses. Most recent classifications have focused on the extent of scalp hair loss as a defining feature, but additional clinical aspects of the disease, including location, pattern, and duration of hair loss as well as impact on the patient's quality of life, are also relevant. These various components have typically been used unidimensionally to classify patients. We propose a multidimensional framework to define AA severity that incorporates multiple patient- and illness-related domains. Using such a framework, dermatologists may better assess the severity of the disease for the individual patient beyond the extent of hair loss.

Follicular Melanocytes in Frontal Fibrosing Alopecia: An Immunohistochemical Study With Trichoscopic Correlation.

BACKGROUND: Frontal fibrosing alopecia (FFA) is a scarring alopecia that affects the frontotemporal hairline. Clinically, it may develop with cutaneous hypopigmentation of the affected areas, which has been associated with a reduction in the epidermal melanocyte count. In trichoscopy, peripilar white halos can be observed, which have been associated with fibrosis in other scarring alopecias. OBJECTIVE: To evaluate the trichoscopic, histopathological and immunohistochemical characteristics of the peripilar white halos in FFA patients. MATERIALS AND METHODS: We conducted a descriptive cross-sectional study that included 12 patients with FFA presenting peripilar white halos. Two 2-mm punch trichoscopy-guided biopsies were performed in all patients, one fragment for vertical section and another for horizontal section. The vertical sections were stained with Fontana-Mason and Melan-A. RESULTS: On trichoscopic examination, peripilar white halos ≤ 1 mm in size were observed on the affected scalp. In vertical sections, a reduction in basal melanin pigmentation and a decrease in the melanocyte count in the upper segment of the hair follicle were observed with Fontana-Masson staining and Melan-A immunostaining, respectively. LIMITATIONS: The small sample size and absence of a control group. CONCLUSION: This study shows follicular melanocyte involvement in FFA, and this finding may be associated with the peripilar white halos observed in trichoscopy.

Trichodynia and telogen effluvium in COVID-19 patients: Results of an international expert opinion survey on diagnosis and management.

BACKGROUND: The cutaneous manifestations of COVID-19 may be useful disease markers and prognostic indicators. Recently, postinfectious telogen effluvium and trichodynia have also been reported. OBJECTIVE: To evaluate the presence of trichodynia and telogen effluvium in patients with COVID-19 and describe their characteristics in relation to the other signs and symptoms of the disease. METHODS: Patients with a history of COVID-19 presenting to the clinics of a group of hair experts because of telogen effluvium and/or scalp symptoms were questioned about their hair signs and symptoms in relation to the severity of COVID-19 and associated symptoms. RESULTS: Data from 128 patients were collected. Telogen effluvium was observed in 66.3% of the patients and trichodynia in 58.4%. Trichodynia was associated with telogen effluvium in 42.4% of the cases and anosmia and ageusia in 66.1% and 44.1% of the cases, respectively. In majority (62.5%) of the patients, the hair signs and symptoms started within the first month after COVID-19 diagnosis, and in 47.8% of the patients, these started after 12 weeks or more. LIMITATIONS: The recruitment of patients in specialized hair clinics, lack of a control group, and lack of recording of patient comorbidities. CONCLUSION: The severity of postviral telogen effluvium observed in patients with a history of COVID-19 infection may be influenced by COVID-19 severity. We identified early-onset (<4 weeks) and late-onset (>12 weeks) telogen effluvium.

Eyebrow Regrowth in Patients with Frontal Fibrosing Alopecia Treated with Low-Dose Oral Minoxidil.

INTRODUCTION: The eyebrows are an important facial feature that shape one's physical appearance and play a role in non-verbal communication. Partial or complete eyebrow loss is seen in most patients with frontal fibrosing alopecia (FFA). Despite the scarring nature of FFA, eyebrow hair regrowth has been previously reported. Nevertheless, treatment options and supporting evidence remain scarce. CASE PRESENTATION: We report eyebrow regrowth in 7 patients with FFA treated with low-dose oral minoxidil (OM). CONCLUSION: Low-dose OM could be a promising adjunctive therapy for treatment of the eyebrows in patients with FFA, particularly in early disease.

A Global eDelphi Exercise to Identify Core Domains and Domain Items for the Development of a Global Registry of Alopecia Areata Disease Severity and Treatment Safety (GRASS).

Importance: A recent expert consensus exercise emphasized the importance of developing a global network of patient registries for alopecia areata to redress the paucity of comparable, real-world data regarding the effectiveness and safety of existing and emerging therapies for alopecia areata. Objective: To generate core domains and domain items for a global network of alopecia areata patient registries. Evidence Review: Sixty-six participants, representing physicians, patient organizations, scientists, the pharmaceutical industry, and pharmacoeconomic experts, participated in a 3-round eDelphi process, culminating in a face-to-face meeting at the World Congress of Dermatology, Milan, Italy, June 14, 2019. Findings: Ninety-two core data items, across 25 domains, achieved consensus agreement. Twenty further noncore items were retained to facilitate data harmonization in centers that wish to record them. Broad representation across multiple stakeholder groups was sought; however, the opinion of physicians was overrepresented. Conclusions and Relevance: This study identifies the domains and domain items required to develop a global network of alopecia areata registries. These domains will facilitate a standardized approach that will enable the recording of a comprehensive, comparable data set required to oversee the introduction of new therapies and harness real-world evidence from existing therapies at a time when the alopecia areata treatment paradigm is being radically and positively disrupted. Reuse of similar, existing frameworks in atopic dermatitis, produced by the Treatment of Atopic Eczema (TREAT) Registry Taskforce, increases the potential to reuse existing resources, creates opportunities for comparison of data across dermatology subspecialty disease areas, and supports the concept of data harmonization.

Safety of low-dose oral minoxidil for hair loss: A multicenter study of 1404 patients.

BACKGROUND: The major concern regarding the use of low-dose oral minoxidil (LDOM) for the treatment of hair loss is the potential risk of systemic adverse effects. OBJECTIVE: To describe the safety of LDOM for the treatment of hair loss in a large cohort of patients. METHODS: Retrospective multicenter study of patients treated with LDOM for at least 3 months for any type of alopecia. RESULTS: A total of 1404 patients (943 women [67.2%] and 461 men [32.8%]) with a mean age of 43 years (range 8-86) were included. The dose of LDOM was titrated in 1065 patients, allowing the analysis of 2469 different cases. The most frequent adverse effect was hypertrichosis (15.1%), which led to treatment withdrawal in 14 patients (0.5%). Systemic adverse effects included lightheadedness (1.7%), fluid retention (1.3%), tachycardia (0.9%), headache (0.4%), periorbital edema (0.3%), and insomnia (0.2%), leading to drug discontinuation in 29 patients (1.2%). No life-threatening adverse effects were observed. LIMITATIONS: Retrospective design and lack of a control group. CONCLUSION: LDOM has a good safety profile as a treatment for hair loss. Systemic adverse effects were infrequent and only 1.7% of patients discontinued treatment owing to adverse effects.

Trichoscopy findings of frontal fibrosing alopecia on the eyebrows: A study of 151 cases.

BACKGROUND: Eyebrow loss (madarosis) is a frequent sign of frontal fibrosing alopecia (FFA), and it can be the first sign of the disease. OBJECTIVE: To describe trichoscopy findings of FFA on the eyebrows. METHODS: The analysis included 151 women with histologically proven diagnosis of FFA and eyebrow loss. Trichoscopy of the eyebrow area was performed with either a FotoFinder videodermatoscope or handheld dermoscope DermLite II pro. RESULTS: The most frequent signs on trichoscopy were yellow dots (92.7%), multiple pinpoint dots (79.5%), short thin hairs/vellus (76.2%), black dots (66.2%), and dystrophic hairs (60.9%). Tapering hairs were found in 21 (13.9%) patients and dystrophic hairs in 92 (60.9%) patients. LIMITATIONS: Inner limitations of a case series (there was no comparison with healthy control individuals or patients with other hair disorders) and lack of histologic correlation to the trichoscopy findings. CONCLUSIONS: Although FFA is a scarring alopecia, the most common trichoscopy signs found in the eyebrows are usually related to noncicatricial alopecia. Therefore, in most cases, trichoscopy of the eyebrows does not resemble the trichoscopy of FFA on the scalp. Black dots, dystrophic hairs, and broken hairs are frequent signs. Occasionally, tapered hairs can be present on the eyebrows in FFA, leading to misdiagnosis of alopecia areata.

Risk factors for frontal fibrosing alopecia: A case-control study in a multiracial population.

BACKGROUND: Frontal fibrosing alopecia (FFA) is a chronic cicatricial alopecia with unknown etiology and a worldwide rising incidence. OBJECTIVE: The objective of this study was to evaluate the association of FFA with demographic and exposure factors in a Brazilian multiracial population. METHODS: A multicenter case-control study was conducted in 11 referral centers throughout Brazil. The study was a case-control study that prospectively recruited 902 participants (451 patients with FFA and 451 sex-matched control individuals). Study participants completed a thorough questionnaire comprising variables grouped as baseline demographics, environmental exposure, diet, hormonal factors, allergies, and hair and skin care. RESULTS: When adjusted by sex, age, menopause, and skin color, FFA was associated with hair straightening with formalin (odds ratio [OR], 3.18), use of ordinary (nondermatologic) facial soap (OR, 2.09) and facial moisturizer (OR, 1.99), thyroid disorders (OR, 1.69), and rosacea (OR, 2.08). Smokers (OR, 0.33) and users of antiresidue/clarifying shampoo (OR, 0.35) presented a negative association with FFA. There was no association with the use of sunscreen. LIMITATIONS: Recall bias. CONCLUSIONS: The association with moisturizers, ordinary facial soap, and hair straightening with formalin and the negative association with antiresidue/clarifying shampoo reinforce the possibility of an exogenous particle triggering FFA.

Consensus on the use of oral isotretinoin in dermatology - Brazilian Society of Dermatology.

BACKGROUND: Isotretinoin is a synthetic retinoid, derived from vitamin A, with multiple mechanisms of action and highly effective in the treatment of acne, despite common adverse events, manageable and dose-dependent. Dose-independent teratogenicity is the most serious. Therefore, off-label prescriptions require strict criteria. OBJECTIVE: To communicate the experience and recommendation of Brazilian dermatologists on oral use of the drug in dermatology. METHODS: Eight experts from five universities were appointed by the Brazilian Society of Dermatology to develop a consensus on indications for this drug. Through the adapted DELPHI methodology, relevant elements were listed and an extensive analysis of the literature was carried out. The consensus was defined with the approval of at least 70% of the experts. RESULTS: With 100% approval from the authors, there was no doubt about the efficacy of oral isotretinoin in the treatment of acne, including as an adjunct in the correction of scars. Common and manageable common adverse events are mucocutaneous in nature. Others, such as growth retardation, abnormal healing, depression, and inflammatory bowel disease have been thoroughly investigated, and there is no evidence of a causal association; they are rare, individual, and should not contraindicate the use of the drug. Regarding unapproved indications, it may represent an option in cases of refractory rosacea, severe seborrheic dermatitis, stabilization of field cancerization with advanced photoaging and, although incipient, frontal fibrosing alopecia. For keratinization disorders, acitretin performs better. In the opinion of the authors, indications for purely esthetic purposes or oil control are not recommended, particularly for women of childbearing age. CONCLUSIONS: Approved and non-approved indications, efficacy and adverse effects of oral isotretinoin in dermatology were presented and critically evaluated.

Trichoscopic stages of dissecting cellulitis: a potential complementary tool to clinical assessment.

Dissecting cellulitis is a chronic, progressive, and relapsing inflammatory disease that predominantly affects the vertex and occiput of young Afro-descendent men. It starts with papules and pustules that evolve to nodules, abscesses, and cicatricial alopecia. This article illustrates the evolutive trichoscopy of dissecting cellulitis, from its early phase, through the abscess phase, to the fibrotic cicatricial phase. Trichoscopy complements clinical-pathological classification, representing a complementary tool useful in early diagnosis and monitoring of the patient during treatment.

Frequency of the Types of Alopecia at Twenty-Two Specialist Hair Clinics: A Multicenter Study.

BACKGROUND: The frequency of different types of alopecia is not clearly reported in recent studies. OBJECTIVE: To analyze the frequency of the types of alopecia in patients consulting at specialist hair clinics (SHC) and to assess for global variations. METHODS: Multicenter retrospective study including data from patients evaluated at referral SHC in Europe, America, Africa and Australia. RESULTS: A total of 2,835 patients (72.7% females and 27.3% males) with 3,133 diagnoses of alopecia were included (73% were non-cicatricial and 27% were cicatricial alopecias). In all, 57 different types of alopecia were characterized. The most frequent type was androgenetic alopecia (AGA) (37.7%), followed by alopecia areata (AA) (18.2%), telogen effluvium (TE) (11.3%), frontal fibrosing alopecia (FFA) (10.8%), lichen planopilaris (LPP) (7.6%), folliculitis decalvans (FD) (2.8%), discoid lupus (1.9%) and fibrosing alopecia in a pattern distribution (FAPD) (1.8%). There was a male predominance in patients with acne keloidalis nuchae, dissecting cellulitis and FD, and female predominance in traction alopecia, central centrifugal cicatricial alopecia, FFA, TE, FAPD and LPP. CONCLUSION: AGA followed by AA and TE were the most frequent cause of non-cicatricial alopecia, while FFA was the most frequent cause of cicatricial alopecia in all studied geographical areas.

Trichoteiromania: Good Response to Treatment with N-Acetylcysteine.

Lichen simplex chronicus on the scalp, also known as trichoteiromania, can be difficult to manage, as the therapeutic options are limited to topical or intralesional glucocorticoids. We describe a patient with trichoteiromania, presenting three lichenified pruriginous plaques on different regions of the scalp, associated with fracture and loss of hair shafts. Prior treatment with potent topical glucocorticoids was ineffective. However, treatment with oral N-acetylcysteine (NAC) 1,200 mg/day resulted in complete hair regrowth within 16 weeks. NAC is a safe drug with a good tolerance profile that could be a therapeutic option for patients with trichoteiromania. The potential of NAC has not been completely elucidated, thus more studies will be necessary to confirm its efficacy in the long term for some psychodermatological conditions.